have you done yoga in the past

Once or twiceOnce or twice a yearOnce a month2-4 times a monthOnce a week2-4 times a week5-7 times a week

If Other Explain *

what is your goal(s) of being involved in a yoga program (max 3)

Goals *

To be most effective with your goals please included:

Specific

Measurable

Achievable

Relevant

Time Based

are you currently involved in an exercise program?

Choose One *

YesNo

If yes:

Exercises include (ex: running, strength training, hiking, etc...) *

How many times a week do you exercise *

1234567

Duration of sessions *

15 min30 min45 min60 min90 min120 min and more

Please add more detail if needed *

Health Questions

Do you have any personal history of heart disease (coronary or atherosclerotic disease)?

Choose One *

YesNo

Any personal history of diabetes or other metabolic disease (thyroid,renal,liver)?

Choose One *

YesNo

Any personal history of pulmonary disease, asthma, interstitial lung disease or cystic fibrosis?

Choose One *

YesNo

Have you experienced pain or discomfort in your chest apparently due to blood flow deficiency?

Choose One *

YesNo

Any unaccustomed shortness of breath (perhaps during light exercise)?

Choose One *

YesNo

Have you had any problems with dizziness or fainting?

Choose One *

YesNo

Do you have difficulty breathing while standing or sudden breathing problems at night?

Choose One *

YesNo

Have you experienced a rapid throbbing or fluttering of the heart?

Choose One *

YesNo

Do you suffer from ankle edema (swelling of the ankles)?

Choose One *

YesNo

Have you experienced severe pain in leg muscles during walking?

Choose One *

YesNo

Excel with Grace Waiver

If at any time during the class, you feel discomfort or strain, gently come out of the posture. You may rest at any time during the class. It is important in yoga that you listen to your body, and respect its limits on any given day.

I, the undersigned, understand that yoga is not a substitute for medical attention, examination, diagnosis, or treatment. I should consult a physician prior to beginning any activity program, including yoga. I recognize that it is my responsibility to notify my teacher of any serious illness or injury before every yoga class. I will not perform any postures to the extent of strain or pain.

I plan to participate in the yoga program offered by Jeff Grace. I understand there are inherent risks in participating in a program of yoga. Consequently, I have been examined by a physician of my choice and have obtained his/her approval for my participation in a yoga program within the last sixty (60) days, or have chosen to proceed without the advice of my physician, and in either event, do hereby assume any and all responsibility for my participation. I agree that Jeff Grace or hosting facility shall not be liable or responsible for any injuries to me resulting from my participation in the yoga program or use of equipment, and I expressly release and discharge Jeff Grace from all claims, actions, judgments and the like which I or my heirs, executors, administrators or assigns may have or claim to have as a result of any injury or other damage, which may occur in connection with my participation in the yoga program, whether or not caused by the negligence of such person or persons. This release shall be binding upon my heirs, executors, administrators and assigns.

I understand that signing below indicates acceptance of the release of liability outlined herein and agreement to the terms of the yoga contract

I have read and understand this waiver and agree to all terms within *